PHOTO QUIZ Charles-Jules-Henri Nicolle Myron G. Schultz and David M. Morens Image courtesy of David M. Morens hown in this photograph is Charles-Jules-Henri Nicolle established experimental scientist, who refused it. Charles S(1866–1936), a physician, microbiologist, novelist, then applied and obtained the position. philosopher, and historian. From 1903 until his death in Nicolle arrived in Tunis in 1902, when he was 36 years 1936, he was Director of the Institut Pasteur in Tunis, Tuni- old. North Africa was a good place to study infectious dis- sia. Nicolle’s many accomplishments include the discovery eases, including brucellosis, diphtheria, leishmaniasis, that epidemic typhus is transmitted by body lice (Pediculus leprosy, malaria, measles, Mediterranean spotted fever, humanis corporis), discovery of the phenomenon of inap- relapsing fever, scarlet fever, tuberculosis, and typhus. Of parent infection, and possibly the first isolation of human all the problems Nicolle faced in Tunis, however, epidemic influenza virus after experimental transmission. Nicolle typhus was, in his words, “the most important and the least made many other fundamental contributions to knowledge explored.” He studied it for the next 7 years. He was well of infectious diseases. This year is the centenary of his dis- aware of the clinical presentation of typhus—its triad of fe- covery about typhus transmission, made in the summer of ver, rash, and stupor—and of its link to poverty. Through- 1909, for which he was awarded the 1928 Nobel Prize in out history, typhus had been a highly communicable and Physiology or Medicine. frequently fatal disease. Before it began to be understood Nicolle was born on September 21, 1866, in Rouen, as a single infectious disease distinguished epidemiologi- the ancient capital of Normandy, France. He obtained a cally from typhoid (in the mid to late 19th century), typhus classical education and was greatly attracted to literature, had been considered a collection of distinctive diseases that history, and the arts, interests he nurtured throughout his affected specific populations. It devastated armies during life. Bowing to the wish of his physician father, howev- wars (“war typhus”) and prisoners living under unsani- er, Nicolle studied medicine. After 3 years at the medical tary conditions (“jail typhus” or “jail fever”); it affected school in Rouen, he proceeded to Paris for further train- displaced populations suffering from famine, floods, and ing and received a medical degree from the Institut Pas- other natural disasters; and in general, it was a disease of teur in 1893. At 27 years of age, Nicolle returned to his poverty. hometown, where he served as a member of the medical In Tunis, typhus struck in seasonal waves during the faculty and as Director of the Bacteriological Laboratory at cooler months and disappeared during the summer. It L’École préparatoire de médecine et pharmacie de Rouen. spread through overcrowded prisons, asylums, and tent vil- His 8 years in Rouen were difficult: his position was un- lages, taking a heavy toll in hospitals among admissions tenured, his colleagues were reluctant to accept his modern personnel and sometimes even among examining physi- ideas about bacteriology, and he experienced a hearing loss cians. Most of the doctors in the Tunisian health system, that prevented him from effectively using a stethoscope. especially those in rural districts, had contracted typhus; These challenges may have motivated him to take a leap approximately one third of them died from it. Nicolle’s that he might otherwise not have taken when the post of first encounter with typhus could have potentially been his directorship of the Institut Pasteur in Tunis became open. It last. In 1903, he escaped death when at the last moment was offered to his elder brother, Maurice (1862–1932), an he cancelled a trip to investigate a prison outbreak. His 2 colleagues went on to the prison without him and spent the Author affiliations: Centers for Disease Control and Prevention, night there; both became ill with typhus and died. Atlanta, Georgia, USA (M.G. Schultz); and National Institutes of Nicolle’s discovery of how typhus is transmitted came Health, Bethesda, Maryland, USA (D.M. Morens) from observations at the entrance and waiting room of the DOI: 10.3201/eid1509.090891 Sadiki Hospital, which primarily served indigent patients. 1520 Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 15, No. 9, September 2009 PHOTO QUIZ He often had to step over the bodies of typhus-infected pa- without wasted motion … In the case of tients who had fallen and died at the doorway. Nicolle ob- the louse discovery, Nicolle had carried served that typhus patients who were admitted spread their out no more than a half-dozen decisive infections to others up to the point at which they entered experiments after years of observation of the hospital waiting room. Included among these secondary the disease and its epidemiology. In this cases were persons who took charge of their clothing. How- instance, his experiments were easily ever, patients became completely noninfectious as soon as confirmed. they were bathed and dressed in a hospital uniform. They Indeed, in the year after Nicolle’s typhus discovery, could then enter the general wards without posing a risk to Howard Taylor Ricketts (1871–1910) and Russell Morse others. Once Nicolle realized this, he reasoned that lice on Wilder (1885–1959), working in Mexico, confirmed louse patients’ clothes were most likely the vectors. transmission of typhus. In 1916, Henrique da Rocha-Lima To test his hypothesis about lice, Nicolle requested and (1879–1956) identified the causative organism and named promptly received a chimpanzee (Pan troglodytes) from it Rickettsia prowazeki in memory of Ricketts and Stanis- his mentor, Pierre-Paul-Émile Roux (1853–1933), at the laus Joseph Matthias von Prowazek (1875–1915), both of Paris Institut Pasteur. Nicolle injected the chimpanzee with whom had died of typhus contracted during their scientific blood from a typhus patient. Twenty-four hours later, the investigations. chimpanzee was febrile, had new skin eruptions, and was Although Nicolle is not credited with discovering the prostrate. Because chimpanzees were costly, Nicolle then cause of human influenza, his contributions were seminal. injected a toque macaque (Macaca sinica) with blood from In 1903, when he had just joined the Institut Pasteur in Tu- the ill chimpanzee. Thirteen days later the macaque became nisia, his mentor Émile Roux reviewed the literature on “fil- febrile. Nicolle fed 29 lice on the ill macaque, and over ter-passing” agents (hypothetical subbacterial agents that the next few days transferred the lice to feed on other ma- passed through Berkfeld and Chamberland filters). Roux caques. Eventually, macaques in this latter group became identified 10 of them that he believed to be scientifically ill as well. proven as causative agents of disease, among them what we Thus, in June 1909, Nicolle reproduced typhus in a now know to be viruses and mycoplasmas. Working at Tur- chimpanzee; in August 1909, he demonstrated that lice are key’s Imperial Institute of Bacteriology, Nicolle’s broth- the carriers of typhus; and in September 1909, he commu- er Maurice and colleagues had isolated the filter-passing nicated his discovery to the French Académie des sciences. agent of rinderpest (later characterized as a paramyxovi- In these simple experiments, Charles Nicolle had solved rus). Charles Nicolle, who had also worked with rinderpest, the mystery surrounding the transmission of one of human- was familiar with these new techniques. kind’s most dreaded scourges, a disease that had been a ma- When the deadly influenza pandemic struck in 1918, jor force in shaping world history. Later research showed Nicolle was among the few scientists in the world prepared that the principal transmission method was not the bites of to study its etiology. At the time, the cause of influenza was lice but the excrement of lice rubbed into the skin or eyes. unknown, but many doubted the conventional explanation Hans Zinsser (1878–1940), an American microbiolo- that it was a bacterial disease. Beginning on September 1, gist and historian, dedicated his classical work, Rats, Lice 1918, Nicolle injected Chamberland-filtered and unfiltered and History, to Charles Nicolle “with affectionate friend- sputum samples from ill patients into human volunteers ship.” In his autobiography, Zinsser speaks of Nicolle’s and into monkeys, reproducing in some experiments a fe- qualities as a scientist: brile influenza-like illness. However, the scarcity of clini- Nicolle was one of those men who cal material and the rapidity with which the epidemic ad- achieve their success by long preliminary vanced precluded large-scale controlled studies. Within a thought, before an experiment is few months, a Japanese group appeared to reproduce and formulated, rather than by the frantic extend the results of the 2 French scientists, but other in- and often ill-conceived experimental vestigators had trouble doing so. As the pandemic faded activities that keep lesser men in ant- into endemicity, further experimentation became difficult like agitation... Nicolle did relatively for all researchers. When influenza viruses were eventually few and simple experiments. But every isolated and characterized in mice and in ferrets more than time he did one, it was the result of long a decade later, Nicolle was finally acknowledged as having hours